Form
W-8BEN
(Rev. February 2006) Department of the Treasury Internal Revenue Service
Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding
OMB No. 1545-1621
Section references are to the Internal Revenue Code. See separate instructions. Give this form to the withholding agent or payer. Do not send to the IRS.
Do not use this form for:
Instead, use Form:
• A U.S. citizen or other U.S. person, including a resident alien individual • A person claiming that income is effectively connected with the conduct
W-9
of a trade or business in the United States fore reig ign n pa part rtne nerrshi hip, p, a fo fore reig ign n sim impl ple e tru russt, or a fo fore reig ign n gr gran anto torr tr trus ustt (s (se ee in inst stru ruc cti tio ons fo forr ex exce cept ptio ions ns)) • A fo • A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or government of a U.S. possession that received effectively connected income or that is claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (see instructions)
W-8ECI W-8E W8EC CI or or WW-8 8IM IMY Y W-8ECI or W-8EXP
Note: These entities should use Form W-8BEN if they are claiming treaty benefits or are providing the form only to claim they are a foreign person exempt from backup withholding. A• person acting as an intermediary Note: See instructions for additional exceptions.
Part I
Identification of Beneficial Owner (See instructions.)
1
Name of individual or organization that is the beneficial owner
3
Type of beneficial owner: Grantor trust Central bank of issue
4
2
Corporation
Disregarded entity
Partnership
Complex trust Tax-exempt organization
Estate
Government
International organization
8
Private foundation
Country (do not abbreviate)
Mailing address (if different from above)
U.S. ta taxpayer id identification nu number, ifif required (s (see in instructions) SSN or ITIN Reference number(s) (see instructions)
Foreign ta tax identifying nu number, if an any (o (optional)
a
The beneficial owner is a resident of
b
If required, the U.S. taxpayer identification number is stated on line 6 (see instructions). The beneficial owner is not an individual, derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, meets the requirements of the treaty provision dealing with limitation on benefits (see instructions).
e
within the meaning of the income tax treaty between the United States and that country.
The beneficial owner is not an individual, is claiming treaty benefits for dividends received from a foreign corporation or interest from a U.S. trade or business of a foreign corporation, and meets qualified resident status (see instructions).
d
The beneficial owner is related to the person obligated to pay the income within the meaning of section 267(b) or 707(b), and will file Form 8833 if the amount subject to withholding received during a calendar year exceeds, in the aggregate, $500,000. Special rates and conditions (i (iff app appli lica cabl ble— e—se see e ins instr truc ucti tion ons) s):: The The be bene nefi fici cial al ow owne nerr is is cla claim imin ing g the the pr prov ovis isio ions ns of Ar Arti ticl cle e of th the e treaty identified on line 9a above to claim a % rate of withholding on (specify type of income): . Explain the reasons the beneficial owner meets the terms of the treaty article:
Part III 11
7
EIN
I certify that (check all that apply):
c
10
Country (do not abbreviate)
Claim of Tax Treaty Benefits (if applicable)
Part II 9
Simple trust
Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.
City or town, state or province. Include postal code where appropriate. 6
Country of incorporation or organization
Individual
City or town, state or province. Include postal code where appropriate. 5
W-8IMY
Notional Principal Contracts I have provided or will provide a statement that identifies those notional principal contracts from which the income is not effectively connected with the conduct of a trade or business in the United States. I agree to update this statement as required.
Part IV
Certification
Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that: 1 I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates, 2 The beneficial owner is not a U.S. person, 3 The income to which this form relates is (a) not effectively connected with the conduct of a trade or business in the United States, (b) effectively connected but is not subject to tax under an income tax treaty, or (c) the partner’s share of a partnership’s effectively connected income, and 4 For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions. Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or any withholding agent that can disburse or make payments of the income of which I am the beneficial owner.
Sign Here
Sign Si gnat atur ure e of ben benef efic icia iall owne ownerr (or (or indi indivi vidu dual al aut autho hori rize zed d to sig sign n for for bene benefic ficia iall owne owner) r)
For Paperwork Reduction Act Notice, see separate instructions.
Date Da te (MM (MM-DD -DD-Y -YYY YYY) Y)
Cat. No. 25047Z
Capa Ca paci city ty in in whic which h actin acting g Form
W-8BEN
(Rev. 2-2006)
